World class commissioning - a catalyst for change?

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Posted:19 November 2008

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Karen Lynas

As PCTs up and down the country face formal judgement of their commissioning skills for the first time, The King's Fund's Leadership Director Karen Lynas offers her views on the new world class commissioning assurance system.

The world class commissioning assurance system, launched in December 2007 and designed to review and score the performance of PCTs, is now well under way. Performance against long-term strategic objectives is being measured in three main categories: 'health outcomes', 'competencies' and 'governance', using a combination of metrics, evidence gathering and panel review. It's an initiative that has seen a high level of central control and ownership from the Department of Health - down to the detailed breakdown of the competencies, skills and behaviours required, dissemination of board agendas for briefing sessions and the provision of slides detailing how boards should manage their internal communications. All this centrally led intelligence and support is to be welcomed if it provides knowledge, skills and experience that otherwise would have to be expensively replicated locally, but it might be useful to test what this significant investment of resources is actually going to tell us.

The ambition is that embarking on this formal assessment process will help kickstart a process of continuous improvement for PCTs. There is recognition from the centre that PCTs are at the beginning of a journey, and expectations are suitably realistic: no one is expecting the highest level four (world class) scores this time around. However, while PCTs will be forgiven for not operating at world class level yet, they are expected to aspire to it, and this benchmarking process is designed to help track and, hopefully, encourage progress. Presenting an aspirational vision for PCTs as local leaders of the health system is intended to stimulate their performance and generate an appetite for change.

But will the limited scoring scale serve the overall ambition? Given the likelihood that the highest-end level fours will be virtually unused and the level threes infrequently awarded, there will probably be very little granulation in scores. As a result, PCTs who are operating at very different levels may come through the process with very similar scores - so as an objective assessment of relative performance the ratings will tell us very little.

It's more likely that this process will tell us something about the different approaches to control and intervention that have been adopted by the SHAs. A number of SHA chief executives have opted for a more laissez-faire approach, while others tend to greater central control. These different styles will be tested by the results of the assurance process. The more hands-off chief executive is likely to view comparatively positive results as vindication of their strategy: the PCTs are rising to the challenges facing them, developing robust commissioning plans and achieving positive results. Those SHA chief executives who instead have chosen to hold back reserves of funding to lead work at a regional level, have clear performance management intervention strategies and are openly critical of PCT leadership may well see poor results as justification for their continued strategy of central control.

The issue is that the role of the SHA in the process is not a neutral one. They can exert significant influence on the process either directly, by being central to the panel interview process, or indirectly, by making it clear across the patch how self-assessment scores will be regarded. They will be key decision-makers in awarding scores and providing an assessment of PCT performance, and so to some extent they can manage the outcome to suit their preferred approach to performance management.

Comparisons have been made between the assurance process and the foundation trust application assessment process, and though there are stark differences between the two there are also some useful parallels. The FT application process can be a daunting task for boards, but is seen positively by many - it’s transparent, consistent, well-managed, challenging, developmental and tough. Ultimately it’s regarded as good preparation for a board in transition between one world and another. In terms of development, the assurance process could offer all that is good about the FT process, going beyond merely describing the current state, to actively moving things forward. Diagnostic processes can be extremely developmental, but what the FT process reminds us is that the developmental aspect is not a given and needs to be consciously managed by both the SHA and the Department.

When the results of the world class commissioning assurance process have been published in February it will become clear whether or not the scoring system can effectively differentiate between levels of performance. However, In the longer term the critical question is whether this exercise proves to have been a significant and positive part of a wider development that genuinely shifts the performance of PCTs, or an expensive and distracting piece of central command and control that has added little value.